NATIONAL CARDIOVASCULAR CENTER

HARAPAN KITA INDONESIA

PERFUSION DATA RECORD

Date :
PATIENT DATA
Name
Age

:
:

No. MR
BW
HT

:
:
:

BSA
BV

:
:

Anesthetis
Perfusionist

kg
cm
0.00
0

M2
mL

Blood Group/Rh :
Diagnostic Data
Cath

Echo

History

:
:
:
:
:

Surgeon

Diagnose
Prosedure

LABORATORY

Hb
Ht
Alb
BS
PT

Cl
Lac
Ur
Cre

APTT

CK

Na

CKMB

K
Leu

eGFR

Cannulae : Aortic :

Fr
Fr
Fr
Fr

Venous :
CI
3
2.8
2.4
2
1.8
1.5

Flow (L/Menit)
0.00
0.00
0.00
0.00
0.00
0.00

PRIME SOLUTION
Crystalloid :
Colloid
:
Mannitol :
Bicarb
:

ml
ml
ml
ml

Oxygenator :
Tubing :
CARDIOPLEGIA

Heparin :
Blood
:
Other
:

U
mL

TIME

EVENT

FLOW
BLD
O2

PRESSURE
FiO2 MAP
CVP

PA

TEMPERATURE
ALP NASO PERIF

pO2

ABGs/ELECTROLYTES
BE
Lact
Hb
Hct

Pre CPB
On CPB
Cooling
AOX/CPS On

TIME

EVENT
PRE CPB
ON CPB

Total Fluid Added

Urin Output
Pre CPB
:
Intra CPB
:
Post CPB
:

pH

pCO2

ml

HCO3 o2 Sat

Hemofiltration :
ml

ml
ml
ml

Fluid Balance
0

ml

CPB TIME
AOX TIME
Ischemic Time
Circ Arrest Time
ASCP

:
:
:
:
:

BLD

INLINE
PaO2 SVO2

Fluid
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml

LYTES
Na

CL

Ca

Defib
Assist device

Mg

:
:

BS

ACT